State of Connecticut Department of Education Early ...

State of Connecticut Department of Education

Early Childhood Health Assessment Record

(For children ages birth ? 5)

To Parent or Guardian: In order to provide the best experience, early childhood providers must understand your child's health needs. This form requests information from you (Part I) which will be helpful to the health care provider when he or she completes the health evaluation (Part II). State law requires complete primary immunizations and a health assessment by a physician, an advanced practice registered nurse, a physician assistant, or a legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to entering an early childhood program in Connecticut.

Please print

Child's Name (Last, First, Middle)

Birth Date (mm/dd/yyyy)

Male Female

Address (Street, Town and ZIP code)

Parent/Guardian Name (Last, First, Middle)

Home Phone

Cell Phone

Early Childhood Program (Name and Phone Number)

Primary Health Care Provider: Name of Dentist: Health Insurance Company/Number* or Medicaid/Number*

Race/Ethnicity

American Indian/Alaskan Native Hispanic/Latino Black, not of Hispanic origin Asian/Pacific Islander White, not of Hispanic origin Other

Does your child have health insurance? Y N Does your child have dental insurance? Y N Does your child have HUSKY insurance? Y N

If your child does not have health insurance, call 1-877-CT-HUSKY

* If applicable

Part I -- To be completed by parent/guardian.

Please answer these health history questions about your child before the physical examination.

Please circle Y if "yes" or N if "no." Explain all "yes" answers in the space provided below.

Any health concerns

Y N Frequent ear infections

Allergies to food, bee stings, insects Y N Any speech issues

Allergies to medication

Y N Any problems with teeth

Any other allergies Any daily/ongoing medications

Y N Y N

Has your child had a dental examination in the last 6 months

Any problems with vision

Y N Very high or low activity level

Uses contacts or glasses

Y N Weight concerns

Any hearing concerns

Y N Problems breathing or coughing

Developmental -- Any concern about your child's:

1. Physical development

Y N 5. Ability to communicate needs

2. Movement from one place to another

Y N

6. Interaction with others 7. Behavior

3. Social development

Y N 8. Ability to understand

4. Emotional development

Y N 9. Ability to use their hands

Y N Y N Y N

Y N Y N Y N Y N

Y N Y N Y N Y N Y N

Asthma treatment Seizure Diabetes Any heart problems Emergency room visits Any major illness or injury Any operations/surgeries Lead concerns/poisoning Sleeping concerns High blood pressure Eating concerns Toileting concerns

Birth to 3 services Preschool Special Education

Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N

Y N Y N

Explain all "yes" answers or provide any additional information:

Have you talked with your child's primary health care provider about any of the above concerns? Y N

Please list any medications your child will need to take during program hours: All medications taken in child care programs require a separate Medication Authorization Form signed by an authorized prescriber and parent/guardian.

I give my consent for my child's health care provider and early childhood provider or health/nurse consultant/coordinator to discuss the information on this form for confidential use in meeting my child's health and educational needs in the early childhood program.

Signature of Parent/Guardian

ED 191 REV. 8/2011 C.G.S. Section 10-16q, 10-206, 19a.79(a), 19a-87b(c); P.H. Code Section 19a-79-5a(a)(2), 19a-87b-10b(2)

Date

Part II -- Medical Evaluation

ED 191 REV. 8/2011

Health Care Provider must complete and sign the medical evaluation, physical examination and immunization record.

Child's Name

Birth Date

I have reviewed the health history information provided in Part I of this form

(mm/dd/yyyy)

Date of Exam

(mm/dd/yyyy)

Physical Exam

Note: *Mandated Screening/Test to be completed by provider. *HT ____ in/cm ____% *Weight ____ lbs. ____ oz / ____%

Screenings

BMI ____ / ____%

*HC ____ in/cm ____% (Birth ? 24 months)

*Blood Pressure ____ / ____ (Annually at 3 ? 5 years)

*Vision Screening

EPSDT Subjective Screen Completed (Birth to 3 yrs)

EPSDT Annually at 3 yrs (Early and Periodic Screening, Diagnosis and Treatment)

Type:

Right

Left

With glasses

20/

20/

Without glasses 20/

20/

Unable to assess Referral made to: __________________

*Hearing Screening

EPSDT Subjective Screen Completed (Birth to 4 yrs)

EPSDT Annually at 4 yrs (Early and Periodic Screening, Diagnosis and Treatment)

Type:

Right Left

Pass Fail

Pass Fail

Unable to assess Referral made to: __________________

*Anemia: at 9 to 12 months and 2 years

*Hgb/Hct:

*Date

*Lead: at 1 and 2 years; if no result screen between 25 ? 72 months

Lead poisoning ( 10ug/dL) No Yes

*TB: High-risk group? No Yes

Test done: No Yes Date: _______ Results: ___________________________ Treatment: _________________________

*Dental Concerns No Yes Referral made to: __________________

Has this child received dental care in the last 6 months? No Yes

*Result/Level: Other:

*Date

*Developmental Assessment: (Birth ? 5 years) No Yes Results:

Type:

*IMMUNIZATIONS Up to Date or Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED

*Chronic Disease Assessment:

Asthma

No Yes: Intermittent Mild Persistent Moderate Persistent If yes, please provide a copy of an Asthma Action Plan

Rescue medication required in child care setting: No Yes

Severe Persistent

Exercise induced

Allergies

No Yes: ___________________________________________________________________________________________

Epi Pen required:

No Yes

History/risk of Anaphylaxis: No Yes:

Food Insects Latex Medication Unknown source

If yes, please provide a copy of the Emergency Allergy Plan

Diabetes Seizures

No Yes: Type I Type II No Yes: Type: _________________

Other Chronic Disease: ______________________________________ __________________________________________________________

T his child has the following problems which may adversely affect his or her educational experience: Vision Auditory Speech/Language Physical Emotional/Social Behavior

This child has a developmental delay/disability that may require intervention at the program. T his child has a special health care need which may require intervention at the program, e.g., special diet, long-term/ongoing/daily/emergency

medication, history of contagious disease. Specify:___________________________________________________________________________ ______________________________________________________________________________________________________________________ No YesThis child has a medical or emotional illness/disorder that now poses a risk to other children or affects his/her ability to participate

safely in the program. No Yes Based on this comprehensive history and physical examination, this child has maintained his/her level of wellness. No Yes This child may fully participate in the program. No YesThis child may fully participate in the program with the following restrictions/adaptation: (Specify reason and restriction.)

__________________________________________________________________________________________________________ No Yes Is this the child's medical home? I would like to discuss information in this report with the early childhood provider

and/or nurse/health consultant/coordinator.

Signature of health care provider MD / DO / APRN / PA

Date Signed

Printed/Stamped Provider Name and Phone Number

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